Unrealistic Expectations May Lead To Poor Choices At End Of Life: Study

7/21/2016

Joanne Kaldy

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Advance care planning and communication with family members about an elderly
loved one’s conditions, prognosis, and expectations are more important than
ever, especially in light of a new study, which found that many elderly
patients hospitalized at the end of life received invasive and potentially
harmful medical treatments.

“It is not unusual for family members to refuse to accept the fact that
their loved one is naturally dying of old age and its associated complications,
so they pressure doctors to attempt heroic interventions,” said Magnolia
Cardona-Morrell, MPH, PhD, who led the study out of the University of New South
Wales’ Simpson Centre for Health Services Research.

This is partly driven, she suggested, by advances in technology and medicine
that have led people to have unrealistic expectations. Additionally, she said, “Doctors
also struggle with the uncertainty of the duration of the dying trajectory and
are torn by the ethical dilemma of delivering what they were trained to do,
save lives, versus respecting the patient’s right to die with dignity.”

Cardona-Morrell and her colleagues analyzed 38 studies over two decades,
based on data from 1.2 million patients, bereaved relatives, and clinicians in
10 countries. They found the practice of doctors initiating excessive medical
or surgical treatment on elderly patients in the last six months of their life
continues worldwide. The study revealed that 33 percent of elderly patients
with advanced, irreversible chronic conditions were given non-beneficial
interventions such as admission to intensive care or chemotherapy in the last
two weeks of life, while others who had not-for-resuscitation orders were still
given cardio pulmonary resuscitation (CPR).

The researchers also found evidence of invasive procedures, unnecessary
imaging and blood tests, intensive cardiac monitoring, and concurrent treatment
of other multiple acute conditions with complex medications that made little or
no difference to the outcome, but which could prevent a comfortable death for
the individuals.

“Our findings indicate the persistent ambiguity or conflict about what
treatment is deemed beneficial and a culture of ‘doing everything possible,’” Cardona-Morrell
said. “The lack of agreed definitions in the medical community of what
constitutes ‘treatment futility’ also makes a global dialogue challenge.

“However, using data from these
studies, we have defined as nonbeneficial those procedures or medical
treatments administered to elderly people in terminal stages of disease which
prolong suffering rather than survival, that can potentially cause harm, are
sometimes given against patients’ wishes, and are unlikely to improve the
person’s health or quality of remaining life.”

It isn’t surprising that patients and families think that extreme measures
such as CPR will have positive results. They see resuscitations in movies and
television, the vast majority of which are highly successful. In fact, the
literature suggests that just 22 percent of elders may survive initial resuscitation.
Only 10 to 17 percent may survive to discharge, most with impaired function.
Interestingly, chronic illness more than age determines prognosis.

Several studies have found that elderly patients actually welcome
conversations with their practitioners about end-of-life issues such as whether
or not they want CPR. For instance, one study of elderly veterans showed that
most wanted discussions with their physicians about CPR and that most had
overestimated their survival chances after this intervention.

The key to enabling realistic expectations is education, the researchers
said. One study showed that of 371 patients, 41 percent wanted CPR prior to
learning about the probability of survival. Afterwards, only 22 percent said
they would want this intervention.

Other studies have documented the value of end-of-life conversations to
encourage realistic expectations and help patients identify what a “good death”
means to them. For example, one recent report found that structured
communication tools—instead of ad hoc end-of-life decision-making
approaches—may increase the completion of advance directives and improve
advance care planning.

Structured communication may be helpful, especially since end-of-life
conversations aren’t just difficult for patients and families. They also can be
difficult for physicians. In fact, physicians often report finding these talks
stressful and emotionally draining.

Some organization use formal guidelines that encourage and equip
practitioners to talk with patients about issues such as the risks and benefits
associated with CPR and other treatments. These can enable patients and
families to express fears, concerns, and wishes and promote conversations about
expectations and goals of care. These guidelines can make an uncomfortable talk
empowering and productive.